Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

HC RMVL & RPLCMT XTRNL ACCESSIBLE NEPHROURTRL CATH

Facility

$7,982.00

Service Code	HCPCS 50387
Hospital Charge Code	3615038701
Hospital Revenue Code	361
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$8,270.00
Rate for Payer: AlohaCare Medicaid	$2,469.46
Rate for Payer: AlohaCare Medicare	$2,469.46
Rate for Payer: Cash Price	$4,789.20
Rate for Payer: Cash Price	$4,789.20
Rate for Payer: Cash Price	$4,789.20
Rate for Payer: Devoted Health Medicare	$2,716.41
Rate for Payer: Hawaii Medical Service Association ABD	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$8,270.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,469.46
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
Rate for Payer: Health Management Network Commercial	$6,784.70
Rate for Payer: Humana Medicare	$2,469.46
Rate for Payer: Kaiser Permanente Commercial	$5,028.66
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$2,469.46
Rate for Payer: MDX Hawaii PPO	$7,742.54
Rate for Payer: Ohana Health Plan Medicaid	$2,716.41
Rate for Payer: Ohana Health Plan Medicare	$2,469.46
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$2,469.46
Rate for Payer: University Health Alliance Commercial	$5,818.08

HC ROOM DAILY

Facility

$3,125.00

Hospital Charge Code	1200000004
Hospital Revenue Code	120
Min. Negotiated Rate	$2,656.25
Max. Negotiated Rate	$7,250.00
Rate for Payer: Cash Price	$1,875.00
Rate for Payer: Cash Price	$1,875.00
Rate for Payer: Hawaii Western Management Group Commercial	$7,250.00
Rate for Payer: Health Management Network Commercial	$2,656.25
Rate for Payer: MDX Hawaii PPO	$3,031.25
Rate for Payer: University Health Alliance Commercial	$5,923.00

HC ROOM W/ TELEMETRY DAILY

Facility

$5,625.00

Hospital Charge Code	1210000005
Hospital Revenue Code	121
Min. Negotiated Rate	$4,781.25
Max. Negotiated Rate	$7,250.00
Rate for Payer: Cash Price	$3,375.00
Rate for Payer: Cash Price	$3,375.00
Rate for Payer: Hawaii Western Management Group Commercial	$7,250.00
Rate for Payer: Health Management Network Commercial	$4,781.25
Rate for Payer: MDX Hawaii PPO	$5,456.25
Rate for Payer: University Health Alliance Commercial	$5,923.00

HC RPL GASTR TUBE WO IMG/END GUID

Facility

$968.00

Service Code	HCPCS 43762
Hospital Charge Code	4504376201
Hospital Revenue Code	450
Min. Negotiated Rate	$822.80
Max. Negotiated Rate	$938.96
Rate for Payer: Cash Price	$580.80
Rate for Payer: Health Management Network Commercial	$822.80
Rate for Payer: MDX Hawaii PPO	$938.96

HC RPL GASTR TUBE WO IMG/END GUID

Facility

$968.00

Service Code	HCPCS 43762
Hospital Charge Code	4504376201
Hospital Revenue Code	450
Min. Negotiated Rate	$295.16
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$295.16
Rate for Payer: AlohaCare Medicare	$295.16
Rate for Payer: Cash Price	$580.80
Rate for Payer: Cash Price	$580.80
Rate for Payer: Cash Price	$580.80
Rate for Payer: Cash Price	$580.80
Rate for Payer: Devoted Health Medicare	$324.68
Rate for Payer: Hawaii Medical Service Association ABD	$569.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$295.16
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$919.60
Rate for Payer: Health Management Network Commercial	$822.80
Rate for Payer: Humana Medicare	$295.16
Rate for Payer: Kaiser Permanente Commercial	$609.84
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$295.16
Rate for Payer: MDX Hawaii PPO	$938.96
Rate for Payer: Ohana Health Plan Medicaid	$324.68
Rate for Payer: Ohana Health Plan Medicare	$295.16
Rate for Payer: UnitedHealthcare Medicare	$295.16
Rate for Payer: University Health Alliance Commercial	$705.58

HC RSV ID POCT

Facility

$589.00

Service Code	HCPCS 87634
Hospital Charge Code	3068763402
Hospital Revenue Code	306
Min. Negotiated Rate	$52.00
Max. Negotiated Rate	$571.33
Rate for Payer: AlohaCare Medicaid	$70.20
Rate for Payer: AlohaCare Medicare	$70.20
Rate for Payer: Cash Price	$353.40
Rate for Payer: Cash Price	$353.40
Rate for Payer: Devoted Health Medicare	$77.22
Rate for Payer: Hawaii Medical Service Association ABD	$58.84
Rate for Payer: Hawaii Medical Service Association Commercial	$87.75
Rate for Payer: Hawaii Medical Service Association Medicare	$70.20
Rate for Payer: Hawaii Medical Service Association Non-ABD	$96.95
Rate for Payer: Hawaii Western Management Group Commercial	$70.20
Rate for Payer: Health Management Network Commercial	$500.65
Rate for Payer: Humana Medicare	$70.20
Rate for Payer: Kaiser Permanente Commercial	$371.07
Rate for Payer: Kaiser Permanente Medicaid	$300.39
Rate for Payer: Kaiser Permanente Medicare	$70.20
Rate for Payer: MDX Hawaii PPO	$571.33
Rate for Payer: Ohana Health Plan Medicaid	$77.22
Rate for Payer: Ohana Health Plan Medicare	$70.20
Rate for Payer: UnitedHealthcare Medicaid	$52.00
Rate for Payer: UnitedHealthcare Medicare	$70.20
Rate for Payer: University Health Alliance Commercial	$160.32

HC RSV ID POCT

Facility

$589.00

Service Code	HCPCS 87634
Hospital Charge Code	3068763402
Hospital Revenue Code	306
Min. Negotiated Rate	$500.65
Max. Negotiated Rate	$571.33
Rate for Payer: Cash Price	$353.40
Rate for Payer: Health Management Network Commercial	$500.65
Rate for Payer: MDX Hawaii PPO	$571.33

HC RSVP AM PROBE

Facility

$589.00

Service Code	HCPCS 87634
Hospital Charge Code	3068763401
Hospital Revenue Code	306
Min. Negotiated Rate	$500.65
Max. Negotiated Rate	$571.33
Rate for Payer: Cash Price	$353.40
Rate for Payer: Health Management Network Commercial	$500.65
Rate for Payer: MDX Hawaii PPO	$571.33

HC RSVP AM PROBE

Facility

$589.00

Service Code	HCPCS 87634
Hospital Charge Code	3068763401
Hospital Revenue Code	306
Min. Negotiated Rate	$52.00
Max. Negotiated Rate	$571.33
Rate for Payer: AlohaCare Medicaid	$70.20
Rate for Payer: AlohaCare Medicare	$70.20
Rate for Payer: Cash Price	$353.40
Rate for Payer: Cash Price	$353.40
Rate for Payer: Devoted Health Medicare	$77.22
Rate for Payer: Hawaii Medical Service Association ABD	$58.84
Rate for Payer: Hawaii Medical Service Association Commercial	$87.75
Rate for Payer: Hawaii Medical Service Association Medicare	$70.20
Rate for Payer: Hawaii Medical Service Association Non-ABD	$96.95
Rate for Payer: Hawaii Western Management Group Commercial	$70.20
Rate for Payer: Health Management Network Commercial	$500.65
Rate for Payer: Humana Medicare	$70.20
Rate for Payer: Kaiser Permanente Commercial	$371.07
Rate for Payer: Kaiser Permanente Medicaid	$300.39
Rate for Payer: Kaiser Permanente Medicare	$70.20
Rate for Payer: MDX Hawaii PPO	$571.33
Rate for Payer: Ohana Health Plan Medicaid	$77.22
Rate for Payer: Ohana Health Plan Medicare	$70.20
Rate for Payer: UnitedHealthcare Medicaid	$52.00
Rate for Payer: UnitedHealthcare Medicare	$70.20
Rate for Payer: University Health Alliance Commercial	$160.32

HC RT CHEST PT DURING LUNG LAVAGE

Facility

$693.00

Service Code	HCPCS 94667
Hospital Charge Code	4109466702
Hospital Revenue Code	410
Min. Negotiated Rate	$589.05
Max. Negotiated Rate	$672.21
Rate for Payer: Cash Price	$415.80
Rate for Payer: Health Management Network Commercial	$589.05
Rate for Payer: MDX Hawaii PPO	$672.21

HC RT CHEST PT DURING LUNG LAVAGE

Facility

$693.00

Service Code	HCPCS 94667
Hospital Charge Code	4109466702
Hospital Revenue Code	410
Min. Negotiated Rate	$20.34
Max. Negotiated Rate	$672.21
Rate for Payer: AlohaCare Medicaid	$157.18
Rate for Payer: AlohaCare Medicare	$157.18
Rate for Payer: Cash Price	$415.80
Rate for Payer: Cash Price	$415.80
Rate for Payer: Devoted Health Medicare	$172.90
Rate for Payer: Hawaii Medical Service Association Commercial	$196.47
Rate for Payer: Hawaii Medical Service Association Medicare	$157.18
Rate for Payer: Hawaii Western Management Group Commercial	$658.35
Rate for Payer: Health Management Network Commercial	$589.05
Rate for Payer: Humana Medicare	$157.18
Rate for Payer: Kaiser Permanente Commercial	$436.59
Rate for Payer: Kaiser Permanente Medicaid	$353.43
Rate for Payer: Kaiser Permanente Medicare	$157.18
Rate for Payer: MDX Hawaii PPO	$672.21
Rate for Payer: Ohana Health Plan Medicaid	$172.90
Rate for Payer: Ohana Health Plan Medicare	$157.18
Rate for Payer: UnitedHealthcare Medicaid	$20.34
Rate for Payer: UnitedHealthcare Medicare	$157.18
Rate for Payer: University Health Alliance Commercial	$505.13

HC RT CHEST WALL MANIPULATION, INITIAL

Facility

$693.00

Service Code	HCPCS 94667
Hospital Charge Code	4109466701
Hospital Revenue Code	410
Min. Negotiated Rate	$589.05
Max. Negotiated Rate	$672.21
Rate for Payer: Cash Price	$415.80
Rate for Payer: Health Management Network Commercial	$589.05
Rate for Payer: MDX Hawaii PPO	$672.21

HC RT CHEST WALL MANIPULATION, INITIAL

Facility

$693.00

Service Code	HCPCS 94667
Hospital Charge Code	4109466701
Hospital Revenue Code	410
Min. Negotiated Rate	$20.34
Max. Negotiated Rate	$672.21
Rate for Payer: AlohaCare Medicaid	$157.18
Rate for Payer: AlohaCare Medicare	$157.18
Rate for Payer: Cash Price	$415.80
Rate for Payer: Cash Price	$415.80
Rate for Payer: Devoted Health Medicare	$172.90
Rate for Payer: Hawaii Medical Service Association Commercial	$196.47
Rate for Payer: Hawaii Medical Service Association Medicare	$157.18
Rate for Payer: Hawaii Western Management Group Commercial	$658.35
Rate for Payer: Health Management Network Commercial	$589.05
Rate for Payer: Humana Medicare	$157.18
Rate for Payer: Kaiser Permanente Commercial	$436.59
Rate for Payer: Kaiser Permanente Medicaid	$353.43
Rate for Payer: Kaiser Permanente Medicare	$157.18
Rate for Payer: MDX Hawaii PPO	$672.21
Rate for Payer: Ohana Health Plan Medicaid	$172.90
Rate for Payer: Ohana Health Plan Medicare	$157.18
Rate for Payer: UnitedHealthcare Medicaid	$20.34
Rate for Payer: UnitedHealthcare Medicare	$157.18
Rate for Payer: University Health Alliance Commercial	$505.13

HC RT CHEST WALL MANIPULATION,SUBSEQUENT

Facility

$693.00

Service Code	HCPCS 94668
Hospital Charge Code	4109466801
Hospital Revenue Code	410
Min. Negotiated Rate	$589.05
Max. Negotiated Rate	$672.21
Rate for Payer: Cash Price	$415.80
Rate for Payer: Health Management Network Commercial	$589.05
Rate for Payer: MDX Hawaii PPO	$672.21

HC RT CHEST WALL MANIPULATION,SUBSEQUENT

Facility

$693.00

Service Code	HCPCS 94668
Hospital Charge Code	4109466801
Hospital Revenue Code	410
Min. Negotiated Rate	$16.41
Max. Negotiated Rate	$672.21
Rate for Payer: AlohaCare Medicaid	$157.18
Rate for Payer: AlohaCare Medicare	$157.18
Rate for Payer: Cash Price	$415.80
Rate for Payer: Cash Price	$415.80
Rate for Payer: Devoted Health Medicare	$172.90
Rate for Payer: Hawaii Medical Service Association Commercial	$196.47
Rate for Payer: Hawaii Medical Service Association Medicare	$157.18
Rate for Payer: Hawaii Western Management Group Commercial	$658.35
Rate for Payer: Health Management Network Commercial	$589.05
Rate for Payer: Humana Medicare	$157.18
Rate for Payer: Kaiser Permanente Commercial	$436.59
Rate for Payer: Kaiser Permanente Medicaid	$353.43
Rate for Payer: Kaiser Permanente Medicare	$157.18
Rate for Payer: MDX Hawaii PPO	$672.21
Rate for Payer: Ohana Health Plan Medicaid	$172.90
Rate for Payer: Ohana Health Plan Medicare	$157.18
Rate for Payer: UnitedHealthcare Medicaid	$16.41
Rate for Payer: UnitedHealthcare Medicare	$157.18
Rate for Payer: University Health Alliance Commercial	$505.13

HC RT CONTINUOUS INHALATION TX, 1ST HR

Facility

$693.00

Service Code	HCPCS 94644
Hospital Charge Code	4109464401
Hospital Revenue Code	410
Min. Negotiated Rate	$27.58
Max. Negotiated Rate	$672.21
Rate for Payer: AlohaCare Medicaid	$157.18
Rate for Payer: AlohaCare Medicare	$157.18
Rate for Payer: Cash Price	$415.80
Rate for Payer: Cash Price	$415.80
Rate for Payer: Devoted Health Medicare	$172.90
Rate for Payer: Hawaii Medical Service Association Commercial	$196.47
Rate for Payer: Hawaii Medical Service Association Medicare	$157.18
Rate for Payer: Hawaii Western Management Group Commercial	$658.35
Rate for Payer: Health Management Network Commercial	$589.05
Rate for Payer: Humana Medicare	$157.18
Rate for Payer: Kaiser Permanente Commercial	$436.59
Rate for Payer: Kaiser Permanente Medicaid	$353.43
Rate for Payer: Kaiser Permanente Medicare	$157.18
Rate for Payer: MDX Hawaii PPO	$672.21
Rate for Payer: Ohana Health Plan Medicaid	$172.90
Rate for Payer: Ohana Health Plan Medicare	$157.18
Rate for Payer: UnitedHealthcare Medicaid	$27.58
Rate for Payer: UnitedHealthcare Medicare	$157.18
Rate for Payer: University Health Alliance Commercial	$505.13

HC RT CONTINUOUS INHALATION TX, 1ST HR

Facility

$693.00

Service Code	HCPCS 94644
Hospital Charge Code	4109464401
Hospital Revenue Code	410
Min. Negotiated Rate	$589.05
Max. Negotiated Rate	$672.21
Rate for Payer: Cash Price	$415.80
Rate for Payer: Health Management Network Commercial	$589.05
Rate for Payer: MDX Hawaii PPO	$672.21

HC RT CONTINUOUS INHALATION TX, EACH ADD HR

Facility

$423.00

Service Code	HCPCS 94645
Hospital Charge Code	4109464501
Hospital Revenue Code	410
Min. Negotiated Rate	$359.55
Max. Negotiated Rate	$410.31
Rate for Payer: Cash Price	$253.80
Rate for Payer: Health Management Network Commercial	$359.55
Rate for Payer: MDX Hawaii PPO	$410.31

HC RT CONTINUOUS INHALATION TX, EACH ADD HR

Facility

$423.00

Service Code	HCPCS 94645
Hospital Charge Code	4109464501
Hospital Revenue Code	410
Min. Negotiated Rate	$10.46
Max. Negotiated Rate	$410.31
Rate for Payer: Cash Price	$253.80
Rate for Payer: Cash Price	$253.80
Rate for Payer: Hawaii Western Management Group Commercial	$401.85
Rate for Payer: Health Management Network Commercial	$359.55
Rate for Payer: Kaiser Permanente Commercial	$266.49
Rate for Payer: Kaiser Permanente Medicaid	$215.73
Rate for Payer: MDX Hawaii PPO	$410.31
Rate for Payer: UnitedHealthcare Medicaid	$10.46
Rate for Payer: University Health Alliance Commercial	$308.32

HC RT CPAP NON-EMERGENT

Facility

$1,092.00

Service Code	HCPCS 94660
Hospital Charge Code	4109466001
Hospital Revenue Code	410
Min. Negotiated Rate	$928.20
Max. Negotiated Rate	$1,059.24
Rate for Payer: Cash Price	$655.20
Rate for Payer: Health Management Network Commercial	$928.20
Rate for Payer: MDX Hawaii PPO	$1,059.24

HC RT CPAP NON-EMERGENT

Facility

$1,092.00

Service Code	HCPCS 94660
Hospital Charge Code	4109466001
Hospital Revenue Code	410
Min. Negotiated Rate	$39.67
Max. Negotiated Rate	$1,059.24
Rate for Payer: AlohaCare Medicaid	$258.69
Rate for Payer: AlohaCare Medicare	$258.69
Rate for Payer: Cash Price	$655.20
Rate for Payer: Cash Price	$655.20
Rate for Payer: Devoted Health Medicare	$284.56
Rate for Payer: Hawaii Medical Service Association Commercial	$323.36
Rate for Payer: Hawaii Medical Service Association Medicare	$258.69
Rate for Payer: Hawaii Western Management Group Commercial	$1,037.40
Rate for Payer: Health Management Network Commercial	$928.20
Rate for Payer: Humana Medicare	$258.69
Rate for Payer: Kaiser Permanente Commercial	$687.96
Rate for Payer: Kaiser Permanente Medicaid	$556.92
Rate for Payer: Kaiser Permanente Medicare	$258.69
Rate for Payer: MDX Hawaii PPO	$1,059.24
Rate for Payer: Ohana Health Plan Medicaid	$284.56
Rate for Payer: Ohana Health Plan Medicare	$258.69
Rate for Payer: UnitedHealthcare Medicaid	$39.67
Rate for Payer: UnitedHealthcare Medicare	$258.69
Rate for Payer: University Health Alliance Commercial	$795.96

HC RT CPT SUBSEQUENT

Facility

$693.00

Service Code	HCPCS 94668
Hospital Charge Code	4109466802
Hospital Revenue Code	410
Min. Negotiated Rate	$589.05
Max. Negotiated Rate	$672.21
Rate for Payer: Cash Price	$415.80
Rate for Payer: Health Management Network Commercial	$589.05
Rate for Payer: MDX Hawaii PPO	$672.21

HC RT CPT SUBSEQUENT

Facility

$693.00

Service Code	HCPCS 94668
Hospital Charge Code	4109466802
Hospital Revenue Code	410
Min. Negotiated Rate	$16.41
Max. Negotiated Rate	$672.21
Rate for Payer: AlohaCare Medicaid	$157.18
Rate for Payer: AlohaCare Medicare	$157.18
Rate for Payer: Cash Price	$415.80
Rate for Payer: Cash Price	$415.80
Rate for Payer: Devoted Health Medicare	$172.90
Rate for Payer: Hawaii Medical Service Association Commercial	$196.47
Rate for Payer: Hawaii Medical Service Association Medicare	$157.18
Rate for Payer: Hawaii Western Management Group Commercial	$658.35
Rate for Payer: Health Management Network Commercial	$589.05
Rate for Payer: Humana Medicare	$157.18
Rate for Payer: Kaiser Permanente Commercial	$436.59
Rate for Payer: Kaiser Permanente Medicaid	$353.43
Rate for Payer: Kaiser Permanente Medicare	$157.18
Rate for Payer: MDX Hawaii PPO	$672.21
Rate for Payer: Ohana Health Plan Medicaid	$172.90
Rate for Payer: Ohana Health Plan Medicare	$157.18
Rate for Payer: UnitedHealthcare Medicaid	$16.41
Rate for Payer: UnitedHealthcare Medicare	$157.18
Rate for Payer: University Health Alliance Commercial	$505.13

HC RT DEMO &/OR EVAL,PT USE,AEROSOL DEVICE

Facility

$1,092.00

Service Code	HCPCS 94664
Hospital Charge Code	4109466401
Hospital Revenue Code	410
Min. Negotiated Rate	$14.35
Max. Negotiated Rate	$1,059.24
Rate for Payer: AlohaCare Medicaid	$258.69
Rate for Payer: AlohaCare Medicare	$258.69
Rate for Payer: Cash Price	$655.20
Rate for Payer: Cash Price	$655.20
Rate for Payer: Devoted Health Medicare	$284.56
Rate for Payer: Hawaii Medical Service Association Commercial	$323.36
Rate for Payer: Hawaii Medical Service Association Medicare	$258.69
Rate for Payer: Hawaii Western Management Group Commercial	$1,037.40
Rate for Payer: Health Management Network Commercial	$928.20
Rate for Payer: Humana Medicare	$258.69
Rate for Payer: Kaiser Permanente Commercial	$687.96
Rate for Payer: Kaiser Permanente Medicaid	$556.92
Rate for Payer: Kaiser Permanente Medicare	$258.69
Rate for Payer: MDX Hawaii PPO	$1,059.24
Rate for Payer: Ohana Health Plan Medicaid	$284.56
Rate for Payer: Ohana Health Plan Medicare	$258.69
Rate for Payer: UnitedHealthcare Medicaid	$14.35
Rate for Payer: UnitedHealthcare Medicare	$258.69
Rate for Payer: University Health Alliance Commercial	$795.96

HC RT DEMO &/OR EVAL,PT USE,AEROSOL DEVICE

Facility

$1,092.00

Service Code	HCPCS 94664
Hospital Charge Code	4109466401
Hospital Revenue Code	410
Min. Negotiated Rate	$928.20
Max. Negotiated Rate	$1,059.24
Rate for Payer: Cash Price	$655.20
Rate for Payer: Health Management Network Commercial	$928.20
Rate for Payer: MDX Hawaii PPO	$1,059.24

Know your out-of-pocket cost for care.

All Charges